Tumble Kids Billerica
2014-2015 Registration Form
29 Cook Street Billerica, MA
978‐667‐1604
tumblekidsbillerica@gmail.com
Child’s
Name:_________________________________________Age:________M___F___Birthdate:______/______/_____
Parent/Guardian Name: ________________________________________Relation: _______________________
Parent/Guardian Name: ________________________________________Relation: _______________________
Address:_____________________________________________________________________________________
Town:__________________________________________________________State:________ Zip ____________
Home Phone: (_______)__________-______________ Cell Phone: (______)________-_____________
E-mail address:_______________________________________________________
Emergency Contact:____________________________________Relation:__________________
Phone: (_____)______-_______
Does your child have any neurological, sensory, physical, or behavioral issues? Y:___ N:___
If YES, please explain:
_____________________________________________________________________________________
Please indicate your first and second choice of class time.
1st choice: CLASS______________________ DAY____________________TIME____________
2nd choice: CLASS______________________ DAY__________________TIME______________
**Availability is not guaranteed.
Tuition: $____________ Registration Fee: $_______ Date Paid:_______________
Payment type: Mastercard/ Visa/Discover/Check (#_____)/Cash
CC# ______________________________________________________________ EXP: _____________________
Name on card: _____________________________________________________________ ZIP: _____________
I authorize Tumble Kids Billerica to process my credit card for services rendered and/or charges due.
Authorized Signature _______________________________________________________ Date:______________
*****Liability Waiver on backside of this registration form is required for participation.*****